NRNP 6635 Week 4 Assignment: Assessing and Diagnosing Patients with Anxiety Disorders, PTSD and OCD Example

Subjective:

Biodata

Name: Sergeant Berry Sullivan

Gender: Male

Age: 27 years

CC (chief complaint): “My fiancé demanded that I make an appointment. I’ve been feeling on edge and having trouble sleeping since I left the military.”

History of Presenting Illness (HPI)

Sergeant Berry Sullivan reports significant anxiety, hypervigilance, and sleep disturbances since leaving the military six months ago. Recently, he had a severe panic attack during a county fair triggered by unexpected fireworks, causing him to run and seek cover. Additionally, he reacts strongly to other loud noises, such as car backfires and sudden loud sounds. Certain smells, like diesel fuel and burning hair, evoke distressing memories related to traumatic events during his service.

Sergeant Berry Sullivan’s symptoms are further exacerbated by frequent nightmares and flashbacks, which contribute to his insomnia. He actively avoids situations that might trigger these distressing reactions. Specifically, Sullivan experiences severe anxiety in traffic, especially when he feels trapped, as it reminds him of the risk of improvised explosive device (IED) attacks. Additionally, he reports heightened irritability and a strong desire to isolate himself from social interactions. During stressful situations, he exhibits physical symptoms such as sweating, shaking, and nausea.

Past Psychiatric History:

• General Statement: No prior history of psychiatric treatment or substance use.
• Caregivers (if applicable): Not applicable
• Hospitalizations: No prior history of hospitalization
• Medication trials: Currently not on any medication
• Psychotherapy or Previous Psychiatric Diagnosis: None

Substance Current Use and History: Denies any history of drug use. Avoids alcohol due to his father’s history of abuse.

Family Psychiatric/Substance Use History:

• Father: History of alcohol abuse, diabetes mellitus (DM), cirrhosis, hypertension (HTN).
• Paternal grandfather: History of depression.
• No psychiatric or substance use history in immediate siblings.

Psychosocial History:         

Sergeant Berry enlisted in the military after high school and served for eight years in the Marines. He completed three long tours in war zones. Recently engaged, he plans to marry in eight months. Currently, he is attending an online college for accounting. Berry relocated to a different state due to his fiancée’s job opportunity, and he looks forward to having children in the future.”

Medical History:

• Current Medications: None listed
• Allergies:Seasonal allergies
• Reproductive Hx:Not applicable

ROS:

• GENERAL: Reports feeling anxious and difficulty sleeping.
• HEENT: Denies headaches, vision changes, hearing loss, or sinus issues.
• SKIN: Denies rashes or any other skin abnormality
• CARDIOVASCULAR: Denies chest pain or palpitations.
• RESPIRATORY: Reports having service-connected asthma, managed with medication.
• GASTROINTESTINAL: Reports nausea during stressful situations. Denies abdominal pain, diarrhea, or constipation.
• GENITOURINARY: Denies dysuria, frequency, or hematuria.
• NEUROLOGICAL: Denies dizziness, tingling, or weakness.
• MUSCULOSKELETAL: Denies joint pain, muscle aches, or back pain.
• HEMATOLOGIC: Denies easy bruising or bleeding.
• LYMPHATICS: Denies swollen glands or lymph node issues.
• ENDOCRINOLOGIC: Denies polyuria, polydipsia, or thyroid issues.

Objective:

Physical exam:

General: He is alert, cooperative, and well-groomed. However, during the interview, he exhibits slight fidgetiness and anxiety.

Vital Signs:

• Temperature: 98.8°F
• Pulse: 86 bpm
• Respiratory Rate: 18 breaths per minute
• Blood Pressure: 122/70 mmHg